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Evaluation database

Evaluation report

2014 Tajikistan: Youth Friendly Health Services program in Tajikistan

Author: Tamar Gotsadze, MD. PhD, Binusrat Sharipova and Subhon Ashurov

Executive summary

With the aim to continuously improve transparency and use of evaluation, UNICEF Evaluation Office manages the "Global Evaluation Reports Oversight System". Within this system, an external independent company reviews and rates all evaluation reports. Please ensure that you check the quality of this evaluation report, whether it is “Outstanding, Best practice”, “Highly Satisfactory”, “Mostly Satisfactory” or “Unsatisfactory” before using it. You will find the link to the quality rating below, labelled as ‘Part 2’ of the report.


Since 2006, UNICEF has been assisting the Ministry of Health and Social Protection (MoHSP) of the Republic of Tajikistan (RT) to establish, scale up and integrate Youth Friendly Health Services (YFHS) into the extensive network of reproductive health and dermato-venerology centers across Tajikistan. The YFHS programme in Tajikistan evolved in two phases. Initially, the pilot project introduced the concept of YFHS through establishment of youth-friendly ‘cabinets’ in three sites – Dushanbe, Tursun-zade and Isfara. The Civil Society Organization (CSO), Association of Dermato-Venerologists “Zukhra” led the project implementation. The second phase of the YFHS programme started with the implementation of the current UNICEF country programme 2010-2015.

The overall goal of the programme is to reduce behavioural risks amongst vulnerable and at risk young people in terms of susceptibility to HIV/AIDS, STIs, substance (drug) abuse, and unwanted pregnancies by improving access to quality and friendly services within the health system.

UNICEF leveraged resources for the national scale up of YFHS from different partners, including GFATM, CARE International, WHO, UNFPA, PSI and GIZ.  MCH and Sanitary Epidemiological Stations (SES) of the MoHSP together with local hukumats and local health departments implemented the program. The local financial departments of the MoF supported budget allocations and monitored expenditures; and Youth–led NGOs (“Young Generation of Tajikistan”, “Nasli Solim”, “Reproductive Health and Adolescents”, and “Tagribot”) supported enhancement of the outreach network, and provided legal assistance to health service providers and YFHS clients. The program also had collaborating partners represented by: GFATM, as a main donor, WHO, UNFPA, PSI and GIZ.


The main objective of this evaluation is to assess the overall national YFHS programme, with special focus on UNICEF’s contribution through the ‘UNICEF-Tajikistan YFHS programme (2006-2013)’, so as to provide UNICEF, the Government of Tajikistan, and other stakeholders with recommendations on how to sustain, improve, and scale up YFHS.


The evaluation focus areas were assessed against OECD evaluation criteria and the report answers questions stipulated in the TOR. Furthermore, the evaluation also integrates Human Rights (HRB) and equity (EQ) based dimensions. The evaluation questions were informed by i) the UNEG guidance on how to integrate Human Rights HRB & EQ considerations in evaluations  and ii) UNICEF’s equity based evaluation.
The evaluation methodology comprised a mix of site visits and observations, face-to-face in-depth interviews, focus group discussions, desk-based research and review of existing reports, documents and available secondary data including the UIC database and was implemented in three phases. ET carried out all data collection exercises (qualitative as well as quantitative) in randomly selected five districts (Isfara, Kulyab and Gissar districts and the YFHS center in Dushanbe and district Rudaki where no YFHS center is operational). In each sampled site, the evaluation team met key stakeholders, conducted in-depth interviews and FGDs with MARA and vulnerable groups who used YFHS services as well as with those young population who have not utilized services offered by YFHS centres.

Findings and Conclusions:

The YFHS Program is highly relevant and fully aligned to the national health strategy, country’s HIV epidemic context and national priorities, national youth policies and strategies as well as with the country cooperation programme of UNICEF.

UNICEF together with sister UN agencies played a primary role in promotion of youth related issues on the government top agenda. The YFHS Program was designed and implemented with active involvement of key national stakeholders, was informed by the needs and desires of young people and benefited from International best practices.
Program design and implementation approaches less focused on strategies that ensure equal access to health services especially for MARA population and failed to address gender equity issues, thus undermining potential benefits the program could have generated.  
YFHS model design ensures comprehensive package of services and demonstrates good example of partnership between public health system and services operated by civil society.  YFHS program design also addressed all key health system bottlenecks to ensure youth’s continuous access to acceptable and quality friendly health services. Government ensured establishment of sound programme governance structure at national, local and facility levels, though demonstrated weaknesses in monitoring and evaluation of program implementation progress. The GoT and UNICEF linked YFHSP with the education sector and capitalized on the ongoing Life Skills Based Education (LSBE) pilot program. UNICEF was responsive in assisting the government to timely resolve program bottlenecks identified during the implementation.

UNICEF was successful in leveraging resources from the government and other partners. The program spending per expenditure category was relatively efficient except for communications.  Efficiency of YFHS varies across centres.


General Recommendations:
Recommendation #1: Continued support to GOT’s Youth Health Policy -It is recommended that UNICEF ensures continuous support to the GoT’s YFHS programme implementation. 
Recommendation #2: Strengthen inter-agency collaboration- Continue and further improve inter-agency collaboration where all partners, building on their comparative advantage, will have a role to play in supporting the MoHSP in the implementation, scale up and update of YFHS program.
Recommendation #3: Enhance advocacy - The new challenges identified, in the section below, will require promotion of greater linkage and partnership through strengthening of the UNICEF Country Office (CO) technical capacity in the policy advice.

Specific Recommendations:
Recommendation #1: Ensure free access to services for MARA young population-
Recommendation #2: Ensure sufficient funding for medicines, supplies and outreach activities - Inadequate funding of medicines and medical supplies challenges the GoT’s commitment for free YFH services and possibly may further deteriorate with the declining external support. 
Recommendation #3: Build analytical capacity to enable evidence based policy and managerial decisions making.
Recommendation #4: Build health workforce capacity –
Recommendation #5: Elaborate most effective outreach interventions - The evaluation revealed that MARA population is less covered by YFHS. If the government wants to attain stated objective, effective outreach approaches have to be elaborated to ensure that those on the margins of society are aware and able to demand services. This may imply further strengthening of multispectral approaches such as education system as well as other sectors. 
Recommendation #6:  Explore options for YFHS scale-up - Limited number of YFHS centres can undermine targeting a critical mass of MARA. Thus further expansion of YFHS is highly recommended.

Lessons Learned:

 1: Setting the scene - The Tajikistan YFHS program is a good example of building of YFHS introduction on theory, research and practice. 
2: UNICEF a flagman in youth health development - The lesson learned from UNICEF operations in Tajikistan, demonstrates having UNICEF as a leader /driving force increased government ownership of YFHS reform. 
3: Building a firm foundation before scale up - The YFHS program in Tajikistan exhibited the need for establishment of firm foundation -enabling political and legal environment along with securing the public funding for the operation of YFHS centers - before geographical scale-up of the model.
4: Demonstration projects can complement advocacy efforts - Such demonstration project can complement advocacy efforts and promote quick scale of pilot models, through leveraging public and external funding.
5: Securing YFHS in resource-insecure settings - Different models of YFHS have been tested in many resource insecure countries, though sustainability of these models were mostly undermined by the absence and/or lack of public funding after graduation of external assistance. Nevertheless, the example of YFHS model introduction in Tajikistan is exemplary.
6: Public health facilities have greater potential to scale-up and sustain
7: Partnerships are vital in making a difference  - UNICEF has high levels of international expertise, but limited resources. Other developing partners, tend to have greater resources but need specific expertise in shaping their programs. 
8: Both government policy and donor programming should have clearly defined objectives - Both government policy and donor programming should have clearly defined objectives, which can be measured in order to evaluate their effectiveness and ensure evidence based policy making focused on impact.
9: Focus on targeting the most marginalized - Both the government policy and UNICEF/partner programs must be focused on the most vulnerable.

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